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Image of the Month—Diagnosis FREE

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Section Editor: Grace S. Rozycki, MD, MBA

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Arch Surg. 2008;143(6):610. doi:10.1001/archsurg.143.6.610.
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ANSWER: GASTROCOLIC FISTULA ASSOCIATED WITH A GASTRIC ULCER

A biopsy of the gastric lesion revealed no malignant neoplasm, and the histologic origin of the 2 openings was colonic tissue. Computed tomography with contrast enhancement demonstrated a 40 × 40 × 17-mm excavation on the side of the lesser curvature of the stomach and a mass between the bottom of the gastric ulcer and the transverse colon. Barium enema showed backward flow of barium from the transverse colon into the stomach. On laparotomy, the transverse colon was tightly adherent to the posterior wall of the gastric angle and there were no swollen lymph nodes. The transverse colon was successfully isolated from the stomach, and partial transverse colectomy and distal gastrectomy were performed, with reconstruction by means of Billroth I anastomosis and colonic end-to-end anastomosis, respectively. The patient's postoperative course was uneventful. The pathologic examination result was negative for malignant neoplasm. The final diagnosis was gastrocolic fistula associated with a gastric ulcer.

Owing to the widespread use of H2-receptor antagonists and proton-pump inhibitors and the improved screening for Helicobacter pylori, gastrocolic fistula is a rare complication of benign peptic ulcer disease. Gastrocolic fistula was first reported by Bec1in 1897. Soybel et al2reviewed 108 cases of gastrocolic fistula caused by complications of benign gastric ulcer in the English-language literature.

The main causes of gastrocolic fistula include colonic or gastric cancer,3postsurgery status, percutaneous endoscopic gastrostomy,46and inflammatory bowel disease. In recent years, gastrocolic fistula caused by benign gastric ulcer has been reported in patients taking corticosteroids or nonsteroidal anti-inflammatory drugs.2Gastrocolic fistula occurs more commonly in women and in those aged between 50 and 60 years.7Symptoms of gastrocolic fistula consist mainly of diarrhea, malnutrition, fecal halitosis, abdominal pain, nausea, and vomiting fecal content.8

The diagnosis of gastrocolic fistula is best detected using barium enema. Its sensitivity is 90%, and its specificity is 30%. Gastrointestinal and colonic endoscopy is more important, not for the diagnosis but to rule out malignant disease. Abdominal computed tomography provides the same interpretation as gastrointestinal fiberscopy. Although spontaneous resolution of gastrocolic fistula has been reported, surgery remains the main treatment for gastrocolic fistula associated with gastric ulcer.

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Submissions

Due to the overwhelmingly positive response to the Image of the Month, the Archives of Surgeryhas temporarily discontinued accepting submissions for this feature. It is anticipated that requests for submissions will resume in mid-2008. Thank you.

Correspondence:Tomonori Iida, MD, Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo 105-8461, Japan (lgpsurgery@yahoo.co.jp).

Accepted for Publication:January 4, 2007.

Author Contributions:Study concept and design: Iida and Yanaga. Acquisition of data: Iida and Akita. Analysis and interpretation of data: Iida, Akita, Sasaki, and Hanyu. Drafting of the manuscript: Iida. Critical revision of the manuscript for important intellectual content: Iida, Akita, Sasaki, Hanyu, and Yanaga. Administrative, technical, and material support: Iida and Akita. Study supervision: Yanaga.

Financial Disclosure:None reported.

Bec  F De la fistule gastrocolique.  Lyon, France A Rey1897;
Soybel  DIKestenberg  ABrunt  EMBecker  JM Gastrocolic fistula as a complication of benign gastric ulcer: report of four cases and update of the literature. Br J Surg 1989;76 (12) 1298- 1300
PubMed
Tavenor  TSmith  SSullivan  S Gastrocolic fistula: a review of 15 cases and an update of the literature. J Clin Gastroenterol 1993;16 (3) 189- 191
PubMed
Saltzberg  DMAnand  KJuvan  PJoffe  I Colocutaneous fistula: an unusual complication of percutaneous endoscopic gastrostomy. JPEN J Parenter Enteral Nutr 1987;11 (1) 86- 87
PubMed
Stefan  MMHolcomb  GWRoss  AJ Cologastric fistula as a complication of percutaneous endoscopic gastrostomy. JPEN J Parenter Enteral Nutr 1989;13 (5) 554- 556
Huanq  SYLevine  MSRaper  SE Gastrocolic fistula with migration of feeding tube into transverse colon as a complication of percutaneous endoscopic gastrostomy. AJR Am J Roentgenol 2005;184 ((3)(suppl)) S65- S66
Clark  FD Gastrocolic fistula secondary to right gastroepiploic-coronary artery bypass. Can J Surg 2005;48 (5) 417- 418
PubMed
Marshall  SFKnud-Hansen  J Gastrojejunocolic and gastrocolic fistulas. Ann Surg 1957;145 (5) 770- 782
PubMed

Figures

Tables

References

Bec  F De la fistule gastrocolique.  Lyon, France A Rey1897;
Soybel  DIKestenberg  ABrunt  EMBecker  JM Gastrocolic fistula as a complication of benign gastric ulcer: report of four cases and update of the literature. Br J Surg 1989;76 (12) 1298- 1300
PubMed
Tavenor  TSmith  SSullivan  S Gastrocolic fistula: a review of 15 cases and an update of the literature. J Clin Gastroenterol 1993;16 (3) 189- 191
PubMed
Saltzberg  DMAnand  KJuvan  PJoffe  I Colocutaneous fistula: an unusual complication of percutaneous endoscopic gastrostomy. JPEN J Parenter Enteral Nutr 1987;11 (1) 86- 87
PubMed
Stefan  MMHolcomb  GWRoss  AJ Cologastric fistula as a complication of percutaneous endoscopic gastrostomy. JPEN J Parenter Enteral Nutr 1989;13 (5) 554- 556
Huanq  SYLevine  MSRaper  SE Gastrocolic fistula with migration of feeding tube into transverse colon as a complication of percutaneous endoscopic gastrostomy. AJR Am J Roentgenol 2005;184 ((3)(suppl)) S65- S66
Clark  FD Gastrocolic fistula secondary to right gastroepiploic-coronary artery bypass. Can J Surg 2005;48 (5) 417- 418
PubMed
Marshall  SFKnud-Hansen  J Gastrojejunocolic and gastrocolic fistulas. Ann Surg 1957;145 (5) 770- 782
PubMed

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